January 2015 - University of Rochester Medical Center



621030056498500Healthcare COOP Template Excerpted from Healthcare COOP & Recovery Planning: Concepts, Principles, Templates & Resources (Jan 2015) _____________________________________________________Contents TOC \o "1-3" \h \z \u 1. Healthcare Continuity of Operations PAGEREF _Toc413932543 \h 2Purpose PAGEREF _Toc413932544 \h 2Federal Guidance for Continuity of Operations PAGEREF _Toc413932545 \h 2Continuity Guidance Circular (CGC) 1 PAGEREF _Toc413932546 \h 2Continuity Guidance Circular (CGC) 2 PAGEREF _Toc413932547 \h 2Pre-Incident Risk Assessment PAGEREF _Toc413932548 \h 21.4 Healthcare Primary Mission Essential Function & Mission Essential Functions PAGEREF _Toc413932549 \h 41.4.1 Health Care Service Delivery (PMEF) PAGEREF _Toc413932550 \h 41.4.2 Access to Health Workforce (MEF) PAGEREF _Toc413932551 \h 41.4.3 Community/Facility Critical Infrastructure (MEF) PAGEREF _Toc413932552 \h 51.4.4 Access to Healthcare Supply Chain (MEF) PAGEREF _Toc413932553 \h 51.4.5 Access to Medical/Non-Medical Transportation System (MEF) PAGEREF _Toc413932554 \h 51.4.6Healthcare Information Systems (MEF) PAGEREF _Toc413932555 \h 61.4.7Healthcare Administration/Finance (MEF) PAGEREF _Toc413932556 \h 6Sample Hospital Mission Essential Functions PAGEREF _Toc413932557 \h 6Continuity Plan Operational Phases & Implementation PAGEREF _Toc413932558 \h 72. Healthcare Disaster Recovery PAGEREF _Toc413932559 \h 82.1 Purpose PAGEREF _Toc413932560 \h 82.2 Pre-Incident Disaster Recovery Stakeholder Engagement PAGEREF _Toc413932561 \h 82.3 Post-Incident Disaster Recovery Roles & Responsibilities PAGEREF _Toc413932562 \h 9Appendix C:Business Continuity & Recovery Training ........................................................................C-1Appendix D:Continuity Operations Planning Tools.............................................................................. D-1D.1 Interoperable Communications Capabilities ........................................................... D-1 D.2 Alternative Care/Surge Site Locations.................................................................... D-1 D.3 Critical Infrastructure Emergency POCs................................................................. D-2 D.4 Supply Chain Matrix................................................. .............................................. D-2 D.4.1 Supply Chain Points of Contact............................................................................. D-3Appendix E:Glossary and Common Terminology ............................................................................. E-1Healthcare Continuity of OperationsPurposeThe Continuity of Operations Plan provides a mechanism to assist with the implementation of coordinated COOP strategies that initiate activation, relocation, and continuity of operations for the Organization. The Organization COOP is an All-Hazards plan that addresses the full spectrum of threats from natural, manmade, and technological sources including national security emergencies.Federal Guidance for Continuity of OperationsContinuity Guidance Circular (CGC) 1 Continuity Guidance Circular 1 (CGC 1) (PDF), Continuity Guidance for Non-Federal Entities provides guidance for developing continuity plans and programs for the sustainment of essential functions and services. Continuity Guidance Circular (CGC) 2 Continuity Guidance Circular 2 (CGC 2) (PDF 4.1MB), Continuity Guidance for Non-Federal Entities: Mission Essential Functions Identification Process provides planning guidance to assist in identifying essential functions and describes the use of a systematic Business Process Analysis, Business Impact Analysis, and the development of risk mitigation strategies.Pre-Incident Risk Assessment[NAME] has reviewed the following guidance to identify hazards, risks, and vulnerabilities to SHA, regional and local health departments, HCCs, and HCOs.Threat and Hazard Identification & Risk Assessment Your Risks: Identifying Hazards and Estimating Losses Vulnerability Analysis 1: Pre-Identified Hazards and Risks SampleHAZARDNATURALTECHNOLOGICALHUMANRARE MODERATE FREQUENTSHORT VARIES LONGLOW MODERATE HIGH1.4 Continuity ElementsORDERS OF SUCCESSIONThe [NAME] has established and maintained Orders of Succession for key positions in the event leadership is incapable of performing authorized duties. The designation as a successor enables that individual to serve in the same position as the principal in the event of that principal’s death, incapacity, or resignation.Exhibit 2: [NAME] Succession Plan SampleKey Position (Position Title)Successor 1Successor 2Successor 3[LEADERSHIP][LEADERSHIP][LEADERSHIP][OPERATIONS][PLANNING][LOGISTICS][FINANCE/ADMIN]DELEGATION OF AUTHORITYThe [NAME] has established Delegations of Authority to provide successors the legal authority to act on behalf of the Organization for specific purposes and to carry out specific duties. Delegations of Authority will take effect when normal channels of direction are disrupted and will terminate when these channels are reestablished.Exhibit 3: Delegation of Authority Plan SampleAuthority Type of AuthorityPosition Holding AuthorityTriggering ConditionsClose FacilityEmergency authoritySenior LeadershipWhen conditions make coming to/ remaining in the facility unsafeRepresent Organization when engaging Govt. OfficialsAdministrative authoritySenior LeadershipWhen the pre-identified senior leadership is not availableCONTINUITY FACILITIESThe [NAME] has identified continuity facilities to conduct business and/or provide clinical care to maintain essential functions when the original property, host facility, or contracted arrangement where the Organization conducts operations is unavailable for the duration of the continuity event. The table below lists the pre-arranged Alternate Sites, Devolution Sites, and Telework Options.The [NAME] conducts operations at the [XYZ ].Exhibit 4: [NAME] Facility Continuity Plan SampleContinuity FacilityType of FacilityLocation of FacilityAccommodationsContinuity Facility3822065-48260Location of00Location ofCONTINUITY COMMUNICATIONSThe [NAME] maintains a robust and effective communications system to provide connectivity to internal response players, key leadership, and state and federal response and recovery partners. The Organization has established communication requirements that address the following factors:Organizations possess, operate and maintain, or have dedicated access to communication capabilities at their primary facilities, off-sites and pre-identified alternate care sitesOrganization leadership and members possess mobile, in-transit communications capabilities to ensure continuation of incident specific communications between leadership and partner emergency response points of contactOrganizations have signed agreements with other pre-identified alternate care sites to ensure they have adequate access to communication resourcesOrganizations possess interoperable redundant communications that are maintained and operational as soon as possible following a continuity activation, and are readily available for a period of sustained usage for up to 30 days following the eventESSENTIAL RECORDS MANAGEMENTThe [NAME] keeps all essential hardcopy records in a mobile container that can be relocated to alternate sites. In addition, electronic records, plans, and contact lists are maintained by the organization leadership and can be accessed online and retrieved on system hard drives when applicable and appropriate. Access to and use of these records and systems enables the performance of essential functions and reconstitution to normal operations.DEVOLUTION OF CONTROL AND DIRECTIONThe [NAME] devolution option requires the transition of roles and responsibilities for performance of Organization essential functions through pre- authorized delegations of authority and responsibility. The authorities are delegated from Organization leadership to other representatives in order to sustain essential functions for an extended period. The devolution option will be triggered when one or moreOrganization leaders are unable to perform the required duties of the position. The responsibilities of the position will be immediately transferred to designated personnel in the delegation of authority matrix. Personnel delegated to conduct Organization activities will do so until termination of devolution option.Healthcare Primary Mission Essential Function (PMEF) & Mission Essential Functions (MEF’s)Health Care Service Delivery (PMEF) The provision of health care continuity provided in all inpatient and outpatient environments.Essential Supporting Activities include:Determine the extent of disruption to health care service deliveryDetermine if event caused a complete or partial disruption of health care service deliveryDetermine if relocation of health care service delivery to alternate care sites is an option for short-term continuation of serviceWork with local emergency management and regional HCC(s) to obtain assistance in returning to normal health care delivery operationsAccess to Health Workforce (MEF) The ability to deploy a credentialed health workforce to provide patient care to support healthcare service delivery in all environments.Essential Supporting Activities include:Identify medical and nonmedical staffing shortages during response and continuity operationsRecall additional staff incrementally to assist in disaster continuity operationsCoordinate with contracted staffing agencies to increase availability of critical medical staffIntegrate credentialed, licensed, independent practitioners into continuity medical operationsCoordinate with volunteer groups to supplement medical & non-medical personnelDisseminate reports of HCO staffing shortages to local incident management & SHACommunity/Facility Critical Infrastructure (MEF) Fully operational critical community/facility infrastructure including power, water, and sanitation etc.., to support patient care environmentsEssential Supporting Activities include:Determine extent of disruption/loss/damage of facility critical infrastructure Electrical SystemWater SystemVentilationFire Protection SystemFuel SourcesMedical Gas & Vacuum SystemsCommunication InfrastructurePrioritize restoration efforts to meet the operational goals of health care service deliveryDisseminate reports of HCO critical infrastructure disruption/loss/damage to local emergency management and to SHAAdvocate for priority service resumption directly to local incident managementAccess to Healthcare Supply Chain (MEF) Full access to the healthcare supply chain including medical & non-medical supplies, pharmaceuticals, blood products, industrial fuels, and medical gases etc.Essential Supporting Activities include:Determine estimated shortfalls identified during the continuity event of needed supplies for the HCOPrioritize medical and non-medical supply items needed by HCO through medical/surgical supply formulariesRedirect supplies already within the hospitals supply chain to areas first impactedActivate pre-event supply orders with vendorsCoordinate with SHA for supply requestsDisseminate HCO supply chain disruption Sitreps to SHAAccess to Medical/Non-Medical Transportation System (MEF) Fully functional medical & non-medical transportation system that can meet the operational needs of the healthcare sector during the response & continuity phases of an eventEssential Supporting Activities include:Determine additional medical/non-medical transportation needs to support response and continuity operationsIdentify an EMS Coordinator and a Transportation Coordinator to manage patient transportCoordinate with regional EMS/Air Ambulance Providers to close gaps in system transportation needsProvide transportation assistance to staff that may need transportation to facilityDisseminate requests for transportation assistance to local emergency management and SHAHealthcare Information Systems (MEF) Fully functional information technology and communications infrastructure that support high availability of the healthcare sector’s data management and information sharing capability.Essential Supporting Activities include:Determine extent of disruption of communication/information technology capabilities at facilitiesActivate redundant communication capabilities if necessaryCoordinate with local/state emergency management to secure priority service restoration to communication/information technology capabilitiesCoordinate with SHA to disseminate critical response and continuity operations informationHealthcare Administration/Finance (MEF) Fully operational administrative and financial capability including maintaining & updating patient records, adapting to disaster recovery program requirements, payroll continuity, supply chain financing, claims submission, and losses covered by insurance and legal issues.Essential Supporting Activities include:Collect disaster response data to be used in After-Action ReportsModify and maintain healthcare information management practices according to changing program requirements directed by authorizing entitiesCoordinate the use of paper systems to track patients, health issues and other critical data in the event electronic systems are compromisedExplore possible sources of disaster assistance that may be available to an organization; request assistance when appropriateMonitor employee/contractor payment systems; implement alternative payment systems if availableActivate disaster recovery contractsInitiate “disaster orders” to increase supply chain availabilityMonitor and adjust claims submission conditions according to changing federal & state requirementsMonitor, document, and address legal issuesMonitor document losses for the preparation of insurance claimsSample Hospital Mission Essential FunctionsEmergency Services (Emergency Department)Surgical Services (Operating Room)Laboratory Services (Lab)Health Information Technology (HIT)Patient Care Unit (PCU)Central Supply (CS)Human Resources (HR)ObstetricsPharmacy ServicesPublic RelationsFood ServicesSecurityLaundryHealth Information ManagementInfusion ChemotherapyContinuity Plan Operational Phases & ImplementationThe [NAME] continuity implementation process includes the following four phases:Readiness & Preparedness:Develop Continuity of Operations Program (COOP)Review COOP Plans annuallyFacilitate COOP drills and exercises that activate plans in coordination with regional, state and federal plansRevise COOP plans accordinglyActivation:Utilizing state and regional information sharing platforms, initiate an alert and notification to all partners executing the transition from immediate emergency response to COOP activationEstablish appropriate liaisons between LHD/HCC/HCO and state health disaster response and recovery officialsProvide situational updates to response partners, SHA, and local/ regional emergency management through information sharing platforms when applicableIf the event disrupts the availability of response leadership to assist response partners in activating continuity operations procedures, delegation of authority and devolution options will be instituted to ensure continuation of essential functionsContinuity Operations:Prioritize COOP activities to focus on rapid resumption of Mission Essential Functions (MEF) and Essential Supporting Activities (ESA)Develop a Common Operating Picture (COP) to assess and inform key stakeholders of statusCommunicate needs to SHA and local emergency management officials to establish priority resumption of critical servicesInform response partners of available Federal/State/Local resources and the process to access needed infrastructure, supplies, transportation, and human capitalAssist response partners in preparing a reconstitution strategy when transitioning from immediate response activity through continuity operations to the recovery phase of the eventReconstitution:Assist response partners in implementing reconstitution operationsCollect situational assessment data from response partners who are reconstituting healthcare operations and provide updates to SHA and Local/County/State Emergency Management and Recovery personnelPartner through the SHA with State Emergency Management, applicable Federal agenciesEssential Support Functions (ESF), and Federal Recovery Support Functions (RSF) to ensure a timely and smooth transition of HCOs to:Re-Enter Healthcare FacilitiesRe-Open Healthcare FacilitiesRe-Patriation of PatientsResumption of Normal Healthcare Service DeliveryHealthcare Disaster RecoveryPurposeTo establish pre-incident disaster recovery planning and post-incident disaster recovery roles and responsibilities in accordance with the concepts and principles recommended from the National Disaster Recovery Framework (NDRF). Additional guidance was incorporated from the National Guidance for Healthcare System Preparedness, Healthcare System Recovery Capability, and the Public Health Preparedness, Community Recovery Capability.Pre-Incident Disaster Recovery Stakeholder EngagementHealthcare Sector partners should continuously collaborate during pre-disaster recovery planning and mitigation activities to minimize impacts during future events. Below are recommended activities for healthcare sector stakeholder engagement:Individual and Household Healthcare Consumer:To minimize the need for the public to take refuge at local member hospitals, become familiar with the locations and available services at established community shelters; periodically update healthcare sector partners when new shelters openBecome familiar with Federal/State/Local disaster recovery assistance programs that provide coverage for healthcare costs related to the event; facilitate workshops with recovery assistance subject matter experts for HCO finance departments to explore all available optionsPre-plan with healthcare sector partners on continuity of special medical needs during the preparedness and mitigation phases of planning; particular attention should focus on the functional needs of at-risk personsSupport educational awareness campaigns for HCO patient population on proper medication supply management strategies during a disasterPrivate Sector- Healthcare Supply Chain, Healthcare Critical Infrastructure Partners:Build relationships with private sector disaster response and recovery POCs, especially in the healthcare supply chain and healthcare critical infrastructure industriesEngage private sector partners in continuity of operations and disaster recovery planningProvide education opportunities to private sector partners on disaster recovery planning effortsEstablish access protocols for business sector recovery resources that may be available in a post disaster environmentActively recruit appropriate private-sector partners as members of the HCCs, public health disaster recovery workgroups, and statewide disaster recovery planning committeesNon-Profit Sector: Professional, Faith Based, Disaster Recovery OrganizationsBuild relationships with local and regional volunteer, professional, faith based, and disaster recovery organization POCsCo-host stakeholder workshops with non-profit sector partners such as hospital associations, American Red Cross, and Voluntary Organizations Active in Disaster chapters to determine recovery priorities in the regionEngage statewide, local, and regional mental/behavioral health organizations in developing plans, identifying at-risk populations, and sharing resources during the recovery phaseActively recruit appropriate non-profit sector partners as members of the HCCs, public health disaster recovery workgroups, and statewide disaster recovery planning committeesLocal Government:Encourage HCO disaster response leadership to build relationships with Local Disaster Recovery ManagersPre-identify local government recovery resources available to HCOsEstablish Memorandums of Understanding and Agreement (MOU/A) with local governments to share available disaster recovery resourcesSupport planning efforts with local authorities to conduct immediate post-disaster damage assessments for healthcare facilities in the affected areaActively recruit appropriate local government officials as members of the HCCs, public health disaster recovery workgroups, and statewide disaster recovery planning committeesState Government:Through appropriate organizational channels develop relationships with state level recovery personnel, especially those who have authority to act in the health and social services sectorsBecome familiar with statewide disaster recovery plans and identify opportunities where healthcare sector members can benefit from statewide resources and capabilitiesDevelop recovery operations coordination plans and information sharing protocols with state health recovery support functionsActively recruit appropriate state government officials as members of the healthcare sector planning committeesFederal Government:In collaboration with SHA become familiar with the Federal Disaster Recovery Framework and the Recovery Support Function (RSF) Health and Social Services annexDetermine which HCOs would be eligible for federal post-disaster recovery aidEncourage healthcare sector members to attend educational and outreach opportunities that are offered through the state from federal recovery planning officialsWhenever possible, conduct drills and exercises that include federal roles and responsibilities as they relate to statewide disaster recovery operationsPost-Incident Disaster Recovery Roles & ResponsibilitiesDisaster Recovery Roles/Responsibilities include:Prioritize health care service delivery recovery objectives by organizational essential functionsMaintain, modify, and demobilize healthcare workforce according to the needs of thefacilityWork with local emergency management, service providers, and contractors to ensure priority restoration and reconstruction of critical building systemsMaintain and replenish pre-incident levels of medical and non-medical suppliesWork with local, regional, and state Emergency Medical System providers, patient transportation providers, and non-medical transportation providers to restore pre-incident transportation capability and capacityWork with local emergency management, service providers, and contractors to restore information technology and communications systemsPrepare After-Action Reports, Corrective Action and Improvement PlansAppendix D: Continuity Operations Planning Tools603948567437000Interoperable Communications CapabilitiesSHA/LHD/ HCC/HCOPrimary ContactSecondary Contact700/800MHzSatellite PhoneHam RadioHCCBob SmithJane JohnsonYes8816-763-Joe ThatcherHeadquarters 1-800-000-7777Email:1-555-222-0000Email:AWIN Channel 627031General ClassHospital AHospital BNursing HomeAlternative Care/Surge Site LocationsSHA/LHD/ HCC/HCO Admin FacilityEmergency CareAcute CareLow AcuityLong Term CareHCC HQTraining RoomN/AN/AN/AN/AHospital AContracted Hot SiteDeployable ShelterHospital A Sister Facility Reopen Closed WardsAffiliated LTCHospital BNo Admin LocationMobile TrailerNo Acute Care CollegeGymNo LTC CapabilityHospital C Contracted Warm SiteDiversionSister FacilityNetwork Urgent CareSystem LTCNursing HomeAffiliated SystemAffiliated SystemAffiliated SystemAffiliated SystemAffiliated SystemNursing HomeNo Admin LocationClosest ERClosest HospitalNetwork Urgent CareOther LTC w/ bedsDialysis CenterNo Admin LocationClosest ERClosest HospitalCloses HospitalClosest LTCDisaster Alternate Care Facilities Tools Community Call Centers for Crisis Support Shuttered Hospitals to Expand Surge Capacity Infrastructure Emergency POCsCritical InfrastructureService Area(s)SHA/LHDHCC/HCO LiaisonContact InformationWaterMunicipal WaterFrankfurt CountyJane Doe1-469-111-0000EnergyElectric & Gas CompanyInformation TechnologyInternet ProviderTelephone CompanyVOIP VendorTransportationAllied Bus CompanyEMS ProviderAirportSupply Chain MatrixVendor ItemHospital AHospital BLTC FacilityLHDFood & WaterPotable WaterWal-MartCrystal GeyserNestlePolandSpringsFood Item 1Meds/SuppliesOxygen PortableBlood SupplierMedicine 1Medicine 2Medicine 3Utility NeedsBulk Oxygen Vendor ItemHospital AHospital BLTC FacilityLHDGenerator FuelIndustrial WaterPortable RestroomsBack-up GeneratorHeating FuelPlumbing ServicesElectrical ServicesOps SupportLaundry ServicesStaffing (Medical)Staffing (Non-Med)Morgue ServicesMedical WasteHazardous WasteAlternate Care SitesHam RadioOperatorsChild/Dependent CarePet CareTransportationAmbulance 1Ambulance 2Air Ambulance 1Non-Med TransportationD.4.1 Supply Chain Points of ContactVendor NamePrimary ContactSecondary ContactSuppliesSatellitePhoneCardinal HealthJohn Smith Ph/EmailJane Johnson Ph/EmailMedical SuppliesMOU’s/MAA’s with PartnersAgreementFormatFunctionTierParties toAgreementAppendix E:Glossary and Common TerminologyItem/AcronymDefinitionARFAction Request FormsAARAfter Action ReportASPRAssistant Secretary for Preparedness and ResponseCGCContinuity Guidance CircularCONOPSConcept of OperationsCOOPContinuity of Operations ProgramCOPCommon Operating PictureCSCentral SupplyDHSDepartment of Homeland SecurityDOCDepartment of CommerceDODDepartment of DefenseDOIDepartment of the InteriorEMSEmergency Medical ServicesESAEssential Supporting Activities (ESA).ESFEmergency Support FunctionFDRCFederal Disaster Recovery CoordinatorFEMAFederal Emergency Management AgencyHCCHealthcare CoalitionHCOHealthcare OrganizationHHSDepartment of Health and Human ServicesHITHealth Information TechnologyHPPHospital Preparedness ProgramHRHuman ResourcesHSEEPHomeland Security Exercise and Evaluation ProgramHSPDHomeland Security Presidential DirectiveHUDDepartment of Housing and Urban DevelopmentIRCTIncident Response Coordination TeamLDRMLocal Disaster Recovery ManagerLHDLocal Health DepartmentL/RHDLocal/Regional Health DepartmentsMAAMutual Aid AgreementMEFMission Essential FunctionsMOUMemorandum of UnderstandingNDRFNational Disaster Recovery FrameworkNSPDNational Security Presidential DirectivePCUPatient Care UnitPMEFPrimary Mission Essential FunctionPOCPoint of ContactRSFRecovery Support FunctionsSDRCState Disaster Recovery CoordinatorSHAState Health AuthoritySitRepsSituation ReportsTDRCTribal Disaster Recovery CoordinatorUSACEUnited States Army Corps of EngineersVOADVoluntary Organizations Active in Disaster ................
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